Dr. Daniel Hoffman, a urogynecologist specializing in voiding dysfunction, discuss the use of Botox, sacral neuromodulation, and bulking agents in treating overactive bladders. Listen to hear more about patient selection criteria for each treatment, botox and neuromodulation procedure techniques, and treatment side effects and complications.

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SHOW NOTES

This week on the BackTable Urology Podcast, Dr. Jose Silva and Dr. Daniel Hoffman, a urologist specializing in voiding dysfunction, discuss the use of Botox, sacral neuromodulation, and bulking agents in treating overactive bladders.

First, Dr. Hoffman explains his procedure for Botox, which he suggests as a treatment option for patients with neurogenic bladders. He uses Urojet as anesthesia and injects the Botox in 0.5 cc injections following a grid template. Additionally, he saves 1 cc for the trigone of the bladder. He uses 200 units of Botox in patients with neurogenic bladders and 100 units in those with urge incontinence. Additional considerations should be made for patients with additional comorbidities, such as benign prostate hyperplasia and cystitis. For cystitis patients, increased caution around vascularized areas should be exercised. Additionally, Dr. Hoffman recommends assessing the degree of obstruction in BPH patients before treating their incontinence with Botox.

Next, Dr. Hoffman discusses his procedure for sacral neuromodulation, a procedure that he recommends for younger patients with urinary retention. Although he notes that rechargeable and battery-operated devices have equivalent functions, a patient’s ability to use and maintain the device and MRI-compatibility should be considered. He recommends allowing the patient to undergo a percutaneous nerve evaluation (PNE) before inserting a permanent device. After permanent device insertion, some patients may experience chronic pain down the leg. Dr. Hoffman recommends reprogramming the device before performing a lead revision. If a lead is fractured and lost during surgery, he advises urologists against going after the fractured lead—neurosurgery should be consulted instead. Finally, he notes that fecal incontinence may also be mitigated through sacral neuromodulation.

Lastly, Dr. Hoffman notes that bulking agents as a potential therapy for women with stress incontinence because they have little to no side effects compared to the pelvic sling. Because he has noticed that coaptite does not have the same longevity as Botox, he considers Bulkamid as a better choice. Like Botox, bulking agents can be quickly injected in the office and result in minimal patient down time.